{"reporting_entity_name":"BlueCross BlueShield of Tennessee","reporting_entity_type":"THIRD PARTY ADMINISTRATOR","last_updated_on":"2026-08-27","out_of_network":[{"name":"EMERGENCY DEPARTMENT VISIT FOR THE E&M OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY &/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99284","description":"EMERGENCY DEPARTMENT VISIT FOR THE E&M OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY &/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING","allowed_amounts":[{"tin":{"type":"npi","value":"1386183028"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":143.620000000,"providers":[{"billed_charge":1581.000000000,"npi":[1386183028]}]}]}]},{"name":"PRICE MOD REQ WATER CHAMBER FOR HUMIDIFIER, USED WITH PAP DEVICE, REPLACEMENT, EACH","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A7046","description":"PRICE MOD REQ WATER CHAMBER FOR HUMIDIFIER, USED WITH PAP DEVICE, REPLACEMENT, EACH","allowed_amounts":[{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":12.760000000,"providers":[{"billed_charge":23.000000000,"npi":[1568087294]}]}]},{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":12.760000000,"providers":[{"billed_charge":23.000000000,"npi":[1962587832]}]}]}]},{"name":"SCREENING MAMMOGRAPHY, BILATERAL, INCLUDING COMPUTER-AIDED DETECTION WHEN PERFORMED","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"77067","description":"SCREENING MAMMOGRAPHY, BILATERAL, INCLUDING COMPUTER-AIDED DETECTION WHEN PERFORMED","allowed_amounts":[{"tin":{"type":"npi","value":"1881687689"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":58.010000000,"providers":[{"billed_charge":105.000000000,"npi":[1881687689]}]}]}]},{"name":"PRICE MOD REQ FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A7031","description":"PRICE MOD REQ FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH","allowed_amounts":[{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":32.150000000,"providers":[{"billed_charge":82.000000000,"npi":[1568087294]}]}]},{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":32.150000000,"providers":[{"billed_charge":82.000000000,"npi":[1962587832]}]}]}]},{"name":"PRICE MOD REQ OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85% OR > OXYGEN CONCENTRATION AT PRESCRIBED FLOW RATE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"E1390","description":"PRICE MOD REQ OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85% OR > OXYGEN CONCENTRATION AT PRESCRIBED FLOW RATE","allowed_amounts":[{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":75.160000000,"providers":[{"billed_charge":400.000000000,"npi":[1962587832]}]}]}]},{"name":"PRICE MOD REQ PILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIR","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A7033","description":"PRICE MOD REQ PILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIR","allowed_amounts":[{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":14.520000000,"providers":[{"billed_charge":34.000000000,"npi":[1962587832]}]}]},{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":14.520000000,"providers":[{"billed_charge":34.000000000,"npi":[1568087294]}]}]}]},{"name":"SCREENING DIGITAL BREAST TOMOSYNTHESIS, BILATERAL","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"77063","description":"SCREENING DIGITAL BREAST TOMOSYNTHESIS, BILATERAL","allowed_amounts":[{"tin":{"type":"npi","value":"1881687689"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":49.810000000,"providers":[{"billed_charge":110.000000000,"npi":[1881687689]}]}]}]},{"name":"PRICE MOD REQ FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A7030","description":"PRICE MOD REQ FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH","allowed_amounts":[{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":82.910000000,"providers":[{"billed_charge":221.000000000,"npi":[1568087294]}]}]},{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":82.910000000,"providers":[{"billed_charge":221.000000000,"npi":[1962587832]}]}]}]},{"name":"RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"71045","description":"RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW","allowed_amounts":[{"tin":{"type":"npi","value":"1881687689"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":13.480000000,"providers":[{"billed_charge":25.000000000,"npi":[1881687689]}]}]}]},{"name":"COMPUTED TOMOGRAPHY, ABDOMEN & PELVIS; WITH CONTRAST MATERIAL","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"74177","description":"COMPUTED TOMOGRAPHY, ABDOMEN & PELVIS; WITH CONTRAST MATERIAL","allowed_amounts":[{"tin":{"type":"npi","value":"1881687689"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":152.380000000,"providers":[{"billed_charge":252.000000000,"npi":[1881687689]}]},{"allowed_amount":134.840000000,"providers":[{"billed_charge":252.000000000,"npi":[1881687689]}]}]}]},{"name":"PRICE MOD REQ FILTER, DISPOSABLE, USED WITH PAP DEVICE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A7038","description":"PRICE MOD REQ FILTER, DISPOSABLE, USED WITH PAP DEVICE","allowed_amounts":[{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":1.930000000,"providers":[{"billed_charge":7.000000000,"npi":[1568087294]}]}]},{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":1.940000000,"providers":[{"billed_charge":7.000000000,"npi":[1962587832]}]},{"allowed_amount":1.930000000,"providers":[{"billed_charge":7.000000000,"npi":[1962587832]}]}]}]},{"name":"PRICE MOD REQ CPAP DEVICE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"E0601","description":"PRICE MOD REQ CPAP DEVICE","allowed_amounts":[{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":38.960000000,"providers":[{"billed_charge":175.000000000,"npi":[1962587832]}]}]},{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":38.960000000,"providers":[{"billed_charge":175.000000000,"npi":[1568087294]}]}]}]},{"name":"PRICE MOD REQ HEADGEAR USED WITH PAP DEVICE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A7035","description":"PRICE MOD REQ HEADGEAR USED WITH PAP DEVICE","allowed_amounts":[{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":17.170000000,"providers":[{"billed_charge":28.800000000,"npi":[1962587832]}]}]},{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":17.170000000,"providers":[{"billed_charge":28.800000000,"npi":[1568087294]}]}]}]},{"name":"PRICE MOD REQ HUMIDIFIER, HEATED, USED WITH PAP DEVICE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"E0562","description":"PRICE MOD REQ HUMIDIFIER, HEATED, USED WITH PAP DEVICE","allowed_amounts":[{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":13.040000000,"providers":[{"billed_charge":35.000000000,"npi":[1962587832]}]}]},{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":13.040000000,"providers":[{"billed_charge":35.000000000,"npi":[1568087294]}]}]}]},{"name":"PRICE MOD REQ TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH PAP DEVICE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A4604","description":"PRICE MOD REQ TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH PAP DEVICE","allowed_amounts":[{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":37.020000000,"providers":[{"billed_charge":75.000000000,"npi":[1962587832]}]}]},{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":37.020000000,"providers":[{"billed_charge":75.000000000,"npi":[1568087294]}]}]}]},{"name":"PRICE MOD REQ NASAL INTERFACE USED WITH PAP DEVICE, WITH OR WITHOUT HEAD STRAP","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A7034","description":"PRICE MOD REQ NASAL INTERFACE USED WITH PAP DEVICE, WITH OR WITHOUT HEAD STRAP","allowed_amounts":[{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":52.310000000,"providers":[{"billed_charge":138.000000000,"npi":[1568087294]}]}]},{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":52.310000000,"providers":[{"billed_charge":138.000000000,"npi":[1962587832]}]}]}]},{"name":"PRICE MOD REQ CUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EACH","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A7032","description":"PRICE MOD REQ CUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EACH","allowed_amounts":[{"tin":{"type":"npi","value":"1962587832"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":18.040000000,"providers":[{"billed_charge":48.000000000,"npi":[1962587832]}]}]},{"tin":{"type":"npi","value":"1568087294"},"service_code":["01","03","04","05","07","09","11","12","14","15","20","34","41","42","49","50","53","57","60","65","71","72","81","99","02","19","10","16","17","18","58"],"billing_class":"professional","payments":[{"allowed_amount":18.040000000,"providers":[{"billed_charge":48.000000000,"npi":[1568087294]}]}]}]}],"version":"2.0.0"}
